Recipient Lock-in Program. A Centralized Recipient Lock-in Program is in place for the MA FFs and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO will maintain a Recipient Lock-in Program to interface with the Department’s Recipient Lock-in Program, will provide for appropriate professional resources to manage the Program and to cooperate with the Department in all procedures necessary to restrict Members. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Lock-in Program. The PH-MCO must obtain approval from the Department prior to implementing a lock-in, including approval of written policies and procedures and correspondence to Members. The PH-MCO’s process must include: • Identifying Members who are overutilizing and/or misutilizing medical services. • Evaluating the degree of abuse including review of pharmacy and medical claims history, diagnoses and other documentation, as applicable. • Proposing whether the Member should be restricted to obtaining services from a single, designated Provider for a period of five years. • Forwarding case information and supporting documentation to BPI at the address below, for review to determine appropriateness of lock-in and to approve the action. • Upon BPI approval, sending notification via certified mail to Member of proposed lock-in, including reason for lock- in, effective date and length of lock-in, name of designated Provider(s) and option to change Provider, with a copy to BPI. • Sending notification of Member’s lock-in to the designated Provider(s) and the CAO. • Enforcing the lock-ins through appropriate notifications and edits in the claims payment system. • Preparing and presenting case at a DHS Fair Hearing to support lock-in action. • Monitoring subsequent utilization to ensure compliance. • Changing the selected Provider per the Member’s or Provider’s request, within thirty (30) days from the date of the request, with prompt notification to BPI through the Intranet Provider change process. • Continuing a Member lock-in from the previous delivery system as a Member enrolls in a MCO, with written notification to BPI. • Reviewing the Member’s services prior to the end of the five-year period of lock-in to determine if the lock-in should be removed or maintained, with notification of the results of the review to BPI, Member, Provider(s) and CAO. • Performing necessary administrative activities t...
